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The nurse is continuing to assist with the care of the client.

The nurse is assisting with initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.

Administer betamethasone.

Monitor intake and output every hour.

Assist RN with performing a vaginal examination every 12 hr.

Obtain a 24-hr urine specimen.

Provide a low-stimulation environment.

Give antihypertensive medication.

Maintain bedrest.

Answer and Explanation

Correct Answer : A,B,D,E,F,G

Administer betamethasone: Betamethasone is administered to pregnant clients at risk of preterm delivery to promote fetal lung maturity. Given the client's gestational age of 31 weeks and signs of severe preeclampsia, administering corticosteroids is critical to prepare for potential early delivery.
Monitor intake and output every hour: Severe preeclampsia can impair renal function, leading to decreased urine output and worsening fluid retention. Hourly monitoring of intake and output helps detect early signs of renal compromise and fluid overload, both of which require immediate intervention.
Assist RN with performing a vaginal examination every 12 hr: Vaginal examinations are avoided in cases of severe preeclampsia unless absolutely necessary because they can stimulate uterine contractions or introduce infection. Therefore, routinely assisting every 12 hours with vaginal exams is not appropriate in this client's plan of care.
Obtain a 24-hr urine specimen: A 24-hour urine collection assesses the degree of proteinuria and provides a clearer diagnostic picture of the severity of preeclampsia. Quantifying protein excretion helps guide clinical management and decisions about timing of delivery.
Provide a low-stimulation environment: A calm, quiet environment minimizes the risk of seizure activity in clients with severe preeclampsia. Reducing auditory, visual, and environmental stimulation is a standard preventative measure to decrease neurological irritability.
Give antihypertensive medication: Severe hypertension must be promptly treated to prevent complications like stroke, placental abruption, and progression to eclampsia. Administering antihypertensive therapy helps stabilize maternal blood pressure and protects both maternal and fetal health.
Maintain bedrest: Bedrest helps reduce blood pressure and physical stress, promoting better perfusion to the placenta. Although strict bedrest is controversial long-term, short-term bedrest is often used in severe preeclampsia management while stabilization measures are implemented.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

emotional lability: The client’s sudden and intense shifts in mood, such as calling the nurse "horrible" and then later saying the nurse is "the best," are classic signs of emotional lability. This rapid mood instability is a hallmark feature of borderline personality disorder and reflects difficulties regulating emotions.
increased heart rate: An increased heart rate is a physiological response often linked to anxiety, panic, or substance use but is not a defining characteristic of borderline personality disorder. It does not directly represent a core emotional or relational disturbance seen in this disorder.
elevated body temperature: Elevated body temperature is a physical finding associated with infection, inflammation, or drug reactions. It is not a behavioral or psychological symptom related to borderline personality disorder.
tactile hallucinations: Tactile hallucinations, such as feeling sensations that are not there, are associated with psychotic disorders or substance intoxication rather than borderline personality disorder. They are not characteristic features of this condition.
fear of abandonment: Individuals with borderline personality disorder have a profound fear of abandonment, whether real or perceived. This fear often leads to intense emotional reactions and unstable interpersonal relationships, as seen in the client’s extreme reactions toward the nurse.

A. “If I have a health care proxy, then I do not need to have a living will” B. "My health care proxy designee is not able to sign a consent form on my behalf” C. “I do not need to name a relative as my designee in my health care proxy” D. "Once my health care proxy is in place, I relinquish my right to make my own decisions"

Correct Answer is C

Explanation

A. "If I have a health care proxy, then I do not need to have a living will.": A health care proxy and a living will serve different purposes. A living will outlines specific treatment preferences, while a health care proxy designates someone to make decisions. Having one does not eliminate the benefit or need for the other.

B. "My health care proxy designee is not able to sign a consent form on my behalf.": The designee named in a health care proxy is specifically authorized to make healthcare decisions, including signing consent forms, if the client becomes unable to do so themselves.

C. "I do not need to name a relative as my designee in my health care proxy.": A client can choose any competent adult they trust to act as their healthcare proxy; it does not have to be a relative. This flexibility allows clients to select someone they believe will best honor their wishes.

D. "Once my health care proxy is in place, I relinquish my right to make my own decisions.": Having a health care proxy does not remove the client's decision-making rights. The proxy only takes effect if the client becomes unable to make or communicate their own healthcare decisions.

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The nurse is continuing to assist with the care of the client. The nurse is assisting with initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client. The nurse is collecting data from the client. Select words from the choices below to fill in each blank in the following sentence. The nurse should identify that _______ and __________ indicate manifestations of borderline personality disorder.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

A nurse is reinforcing teaching with a client about advance directives and a health care proxy. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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The nurse is continuing to assist with the care of the client.

The nurse is assisting with initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.